Dry Eye and What To Do About It: The Importance of Lid Hygiene 

This is a boring subject but an important one.  Dry eye is likely the single most common complaint an eye doctor encounters. It affects millions of people and can be debilitating. Eyes get dry.  So what?  Well tears are important.

Your tears are:

1) The refractive surface of the eye, which provide the glass smooth surface upon which refracts light is focused.  Insufficient tears means a hazy, out of focus vision.  Have you been reading and all of a sudden the print fades away?  Now you see it; now you don’t?  Dry eye.

2) Highly antimicrobial.  Tears kill many bacteria on contact.  Less tears means more eye infections.

3) Bathe and support the cornea.  Bad tears mean the cornea becomes inflamed which translates into pain.


“Doc, it feels like there is grit in my eye.  I look in the mirror but I don’t see anything.”

“Doc, I can be reading and all of a sudden, the print fades away.”  (My favorite: “The letters grow fur.”

“Doc, my eyes burn and feel tired all the time.”

“Doc, it feels like there’s a hair in my eye.”

(I like being called Doc, by the way, casual yet respectful.)…………………

If I hear these symptoms, especially the “letters growing fur” comment, I think dry eye.

If you’ve been to my practice with these complaints, then no doubt, you will have watched me put this paper loaded with yellow stuff in your eye.  Flourescein is a water soluble dye which is fluorescent.  So when I apply the blue light on it, it glows.  So I can “see” your tear film, which means I can see your tears.  I can tell if your tears cover your eyes and how long.  Fluorescein also is absorbed by damaged cells; so if cells have died, they absorb the dye and GLOW!   Commonly I see dead cells scattered all over the cornea.  OUCH, which explains, “Doc, my eyes are red and irritated; it feels like grit in my eyes; my vision comes and goes, and when I read, the letters grow fur!”

The science so far:

Tears are made up of three layers: a mucus layer, a watery layer, and an oil layer.  The mucus acts to bind the tears to the surface of the eye so the tears can “flow.”  The watery layer keeps the eye wet of course, and the oil layer helps prevent evaporation.  It is now believed that most dry eye cases are caused by a lack of the oil layer, causing  the tears to simply dry up faster than is being produced.  The oil is produced by huge oil glands called meibomian glands.  Dry eye is usually caused by inflammation of these glands.  Bacteria enter the glands and metabolize the oil and transform it into a whitest goo, much like cottage cheese.  If you apply pressure to the gland, clear oil should come out.  As the disease progresses the oil goes from clear to milky to cheesy.  This is called meibomianitis.  Finally, the oil becomes plugged and the oil production stops.  Also, as you might imagine, the gooey, milky oil is full of toxins which when spilled into the eye causes inflammation on the cornea, and the tears evaporate quickly so the individual is left with a dry, inflamed cornea.



Sometimes the watery layer is missing.  In this case, a drug called Restasis is helpful.  It causes tear cells to multiply and can be amazingly effective. I used to prescribe it often and for some it helped immensely but for most it was ineffective.  

So what to do?

First off, to get quick relief, use an over the counter tear drop, Systane Balance or Systane Ultra are good.  Not only do tear drops provide instant moisture to the eye, they also serve to wash away toxins, which reduces inflammation.  The best tear drops are “preservative free” because preservatives can irritate the cornea, especially with long term use.

But the long-term better course is:

Hot Compresses and Lid Massage to clean out those oil glands !!!

                                                           (recall, I did say it was a boring subject)

 The more fundamental treatment is we need to get to the root of the problem, which is ususally but not always the oil (meibomian) glands.  Heat thins out the cheesy material so that massage, i.e. pressure, can express i.e. squeeze it out.

Hot compress and message/expression:

Apply heat to the lids.  It can be a hot shower on your face, or a hot wash cloth.  Apply heat for a minute or so. Then apply pressure to the lashes because that is where the meibomian glands are.  Apply pressure and hold; the excretions are thick, they ooze, so pressure and time is important.

Do  this every day.  In several weeks, symptoms are likely to improve.

There is another treatment, called LipiFlow.  LipiFlow is a device which your lids fit in like a glove into the treatment device  With the lids held in place, heat and pressure is automatically applied to facilitate the meibomian expression.  I hear that the cost of this device is around $100,000, so I don’t own one.  Duke has one, as does Carolina Eye Associates (Southern Pines); and there are many more locations.

Although expression of the glands is the first line of defense, antibiotics also can play a role.  Doxycycline taken orally is very useful.  Doxycycline, in addition to being antimicrobial, also has anti-inflammatory properties.   It is used in dermatology for the treatment of  ache, and not surprisingly is also used to treat lid disease.  When presented with true cottage cheese or toothpaste like excretions, I prescribe this antibiotic.

Update June 2014

Since really stressing to patients the importance of lid hygiene, I have observed many positive effects.  Even when the patient doesn’t have dry eye per se by having lots of tears, the hot compress/expression treatment improves a host of symptoms.  I have observed less irritation of the cornea, less irritation of the lids themselves, and generally more comfortable eyes.  So I now recommend this treatment be done even without obvious dry eye symptoms.  It just seems to improve everything.  So even if your eyes feel fine now, go a head and hot compress and express, you may feel better but more importantly doing so will prevent problems down the road.  We brush out teeth to prevent oral disease; lid hygiene works the same way.

Punctal Plugs.

Every time we blink, our lids literally pump tears down the drainage system of the eye and into the nose.  So if one’s eyes are dry, then tears are being drained away that we would like to keep.  Simply, these plugs plug the opening to the drainage system (the puncta).  For some these plugs can be very helpful.  They are simple to insert and can be removed. There are also temporary collagen plugs which when inserted will plug the duct for about 3 days; they slowly dissolve on their own. This allow people to experience having their puncta plugged but without the expense of the permanent plugs.  In general plugs are converged by insurance.  

© Richard Randolph 2012